Surgical Concepts and Techniques in Pediatric Brachial Plexus … · 2012-05-25 · deformities in...

May 25, 2012 Copyrights by Dr. Rahul K. Nath. 1

Surgical Concepts and Techniques in Pediatric Brachial Plexus Injury

Rahul Nath, MDRahul Nath, MD


Disclaimer

This presentation is intended as an informational resource only for therapists working with peripheral nerve injuries. This is a general outline of Dr. Nath’s management protocols; other specialists may have different protocols. Many other surgeries or therapy management may be indicated in more complex or less complex cases. No attempt to provide specific medical advice is intended. It is not intended to infer that surgery is always the best choice for a particular nerve injury. You should always contact a specialist directly for diagnosis and treatment of your specific problem, and a second opinion is always a good idea.

ALL INFORMATION IS PROVIDED AS A PUBLIC SERVICE AND NEITHER GUARANTEE NOR WARRANTY IS EXPRESSED OR IMPLIED.


Management Protocols areBased on Book:

The Nath Method of Diagnosis and Treatment


“Nerve injury in the brachial plexus of the newborn results in fibrosis of the muscles and eventual bony deformity…”

Whitman R: The treatment of congenital and acquired luxations at the shoulder in childhood. Ann Surg 1905, 42(1):110-115.


Pediatric Plexus Injury vs. Adult Plexus Injury

Growth IssuesGrowth Issues No Growth IssuesNo Growth IssuesMore secondary surgeryMore secondary surgery Less secondary surgeryLess secondary surgery


Contents• ANATOMY• BRACHIAL PLEXUS INJURY• BRACHIAL PLEXUS INJURY OUTCOMES• BRACHIAL PLEXUS SURGERY• CASE STUDIES


Contents • ANATOMY:

–5 roots of the brachial plexus: C5-T1–Upper roots are C5,6–C5 = Shoulder function and growth–C6 = Biceps function and arm

growth


AsymmetricAsymmetric InjuryInjury

Upper Trunk (85%)Upper Trunk (85%)

Lower Roots (15%)Lower Roots (15%)


Contents• BRACHIAL PLEXUS INJURY

– Upper roots are more frequently injured than lower ones: ASYMMETRIC INJURY

– Because injury tends to be ASYMMETRIC, muscle growth is also ASYMMETRIC andleads to MUSCLE IMBALANCES


AsymmetricAsymmetricNerve InjuryNerve Injury

MuscleMuscleImbalancesImbalances

ShoulderShoulderDislocationDislocation


PathophysiologyPathophysiology

+ ==

Explosive LimbExplosive LimbGrowthGrowth Asymmetric InjuryAsymmetric Injury

ScapularDeformity (SHEAR)

Muscle Imbalances


Plexus Injury TypesPlexus Injury Types

••Stretch (Stretch (NeuropraxiaNeuropraxia))••Tear (Rupture/ Avulsion)Tear (Rupture/ Avulsion)


Contents• Outcomes

– Nerve injury = Muscle weakness

– Asymmetric nerve injury = Muscle imbalances

– Muscle imbalances = Shoulder dislocation


Brachial Plexus Injury Outcomes Brachial Plexus Injury Outcomes Based on LiteratureBased on Literature

1.1. Muscle WeaknessMuscle Weakness2.2. Contracture FormationContracture Formation3.3. Shoulder DislocationShoulder Dislocation


1. Muscle Weakness: Affecting Shoulder and Biceps

6 Month- old child with 0/5 Biceps and 0/5 Shoulder


2. Muscle Imbalances: Shoulder Internal Rotators and Adductors become stronger

than External Rotators

5 year old child with Contractures: Restricted Shoulder Abduction


3. Muscle Imbalances are associated with Elevated Scapula and Subluxed

Shoulder Joint

Note: 3D CT Scan shows Left SHEAR Deformity


Contents• Surgery

– Nerve injury tends to be stretch, not tear or avulsion = Infrequent need for nerve graft

– Muscle imbalances are common = Modified quad surgery

– Shoulder joint dislocation is common = Triangle tilt surgery


Brachial Plexus SurgeryBrachial Plexus Surgery

1.1. Nerve Graft/ Repair (Unusual)Nerve Graft/ Repair (Unusual)2.2. Contracture Release (Mod Contracture Release (Mod

quad surgery is common)quad surgery is common)3.3. Bone/ Joint Surgery (Triangle Bone/ Joint Surgery (Triangle

tilt surgery is common)tilt surgery is common)


1. Nerve Graft1. Nerve Graft


Outcome Research: Be cautious about nerve grafting

– Nath RK. Nerve grafting worsens shoulder bony deformities in obstetric brachial plexus injury. J Bone Joint Surg (Br.) 2009.

– Strömbeck C, Krumlinde-Sundholm L, Forssberg H. Functional outcome at 5 years in children with obstetrical brachial plexus palsy with and without microsurgical reconstruction. Dev Med Child Neurol. Mar 2000;42(3):148-157.


Patient After Nerve Grafting: Residual Shoulder Problems are Common


Biceps/ Triceps Co- contraction • In a study of 482 children with brachial plexus

palsies, 2.5% of children developed biceps- triceps cocontractions.– Rollnik JD, Hierner R, Schubert M, et al. Botulinum

toxin treatment of cocontractions after birth-related brachial plexus lesions. Neurology. Jul 12 2000;55(1):112-114.

• Co- contraction is more common cause of “biceps weakness” than actual nerve injury to the biceps nerve


BoToxBoTox (Instead of Nerve Graft)(Instead of Nerve Graft)

• Co-contracture of biceps and triceps

• Effective for triceps (releases biceps)

• Less useful in Latissimus, Teres major, pectoralis, subscapularis


Botox for Biceps/ Triceps Co-contraction

• Basciani M, Intiso D. Botulinum toxin type-A and plaster cast treatment in children with upper brachial plexus palsy. Pediatr Rehabil. Apr-Jun 2006;9(2):165-170.

• DeMatteo C, Bain JR, Galea V, Gjertsen D. Botulinum toxin as an adjunct to motor learning therapy and surgery for obstetrical brachial plexus injury. Dev Med Child Neurol. Apr 2006;48(4):245-252.

• Desiato MT, Risina B. The role of botulinum toxin in the neuro-rehabilitation of young patients with brachial plexus birth palsy. Pediatr Rehabil. Jan-Mar 2001;4(1):29-36.

• Heise CO, Lorenzetti L, Marchese AJ, Gherpelli JL. Motor conduction studies for prognostic assessment of obstetrical plexopathy. Muscle Nerve. Oct 2004;30(4):451-455.

• Hierner R, Rollnik JD, Berger AC, Dengler R. Botulinum toxin type a for the treatment of biceps/triceps co-contraction in obstetrical brachial plexus lesions. Preliminary results after a follow-up of 18 months. Eur J Plast Surg. 2001;24(1):2-6.

• Rollnik JD, Hierner R, Schubert M, et al. Botulinum toxin treatment of cocontractions after birth-related brachial plexus lesions. Neurology. Jul 12 2000;55(1):112-114.


Biceps/ Triceps Co- Contraction

6 Month- old child with 0/5 Biceps and 0/5 Shoulder


Biceps/Triceps Co- Contraction

Same child 18 months old, NO NERVE GRAFTING, Botox to triceps instead


2. Muscle Complications • A far greater number of children will

develop significant contractures in the shoulder. In one study of 62 children, 45% of patients recovering biceps after three weeks developed contractures of the shoulder– Hoeksma AF, Wolf H, Oei SL. Obstetrical

brachial plexus injuries: incidence, natural course and shoulder contracture. Clin Rehabil. Oct 2000;14(5):523-526


Contractures in Axilla/ Chest

5 year old child with Contractures: Restricted Shoulder Abduction: Modified

quad surgery is often indicated


Contractures in Axilla/ Chest

Same 5 year old child After Contracture Releases (Modified quad surgery): Improved Shoulder

Abduction


3. Bony Complications: SHEAR (Scapular Hypoplasia, Elevation

and Rotation) • Many OBPI patients have shoulder bony

and joint deformities due to muscle imbalances:– Birch R (2003). Late sequelae at the shoulder in

obstetric palsy in children.Shoulder Duparc J, editor. Paris, Elsevier. 3: 55-200-E-10.

• Triangle tilt surgery is often indicated


SHEAR: Dislocated Shoulder

Note: 3D CT Scan shows Left SHEAR Deformity


Most Common Result of OBPI is Most Common Result of OBPI is Shoulder Deformity, Pain and Arthritis by Shoulder Deformity, Pain and Arthritis by

Late Teen YearsLate Teen Years


Triangle Tilt Surgery (bottom row) after Triangle Tilt Surgery (bottom row) after Failed Humeral Osteotomy (top row)Failed Humeral Osteotomy (top row)

Shoulder Relocated; normalization of function, increased length;Shoulder Relocated; normalization of function, increased length; improved improved growth; decreased paingrowth; decreased pain


CT Scan results One Year CT Scan results One Year after Triangle Tilt Surgeryafter Triangle Tilt Surgery

A (Therapy Alone) B (Same child as A, After Triangle Tilt Surgery)


3D CT Scans Pre3D CT Scans Pre-- and Postoperatively and Postoperatively


PODCI Parameter

Non-TT Mean(SD)

TT Mean(SD) Change p-value

Upper Extremity 54.1 (23.6) 73.2 (21.7) +19.1 0.0033

Basic Mobility 50.7 (11.5) 77.6 (5.2) +26.9 <0.0001

Sports/Physical 54.8 (14.3) 70.8 (11.3) +16.0 0.013

Pain/Comfort 61.3 (19.6) 66.9 (17.7) +5.6 0.3592

Happiness 52.2 (20.3) 57.7 (17.4) +5.5 0.3514

Global Functioning 52.38 (13) 70.36 (11) +18.0 0.0048

Quality of Life Improvement after Triangle Tilt (TT) Surgery


Nerve Injury (100%) Complete Recovery (50%)

Nerve Complications (2.5%)

Muscle Complications (45%)

Bony Complications (35%)

Joint Deformity (35%)

Dr. Nath’s Management:Numbers are Estimates Based on Experience

and Literature Search

Botox Triceps or Nerve Repair

Mod QuadMod Quad

Triangle TiltTriangle Tilt

This is a general outline of Dr. Nath’s management protocols; other specialists may have different protocols. Many other surgeries or therapy managementmay be indicated in more complex or less complex cases


Details of Dr. Nath’s Management

(1)Paralyzed Biceps: Botox Triceps Shoulder

(2)Contractures: Modified Quad Surgery(3)Bony/Joint Deformities: Triangle Tilt

Surgery


Rationale for Preferred ManagementRationale for Preferred Management

1. Pathophysiology is the basis for management

2. Literature:• Nerve injury tends to recover spontaneously• Muscle injury and contractures common• Bone deformity follows muscle imbalances

3. Experience


Nerve Graft Triangle Tilt


Case Study 1Case Study 1

Contractures of Shoulder After Mod Quad Surgery


Before

Triangle

Tilt

Surgery

After

Triangle

Tilt

Surgery



8 Months Old, Right OBPI


Surgical Procedures Performed at Outside Hospital

1. NERVE GRAFTING2. MUSCLE TRANSFERS3. SHOULDER JOINT RELEASES4. BICEPS TO TRICEPS

TRANSFER WITH ALLOGRAFT 5. BICEPS TENDON ALLOGRAFT6. HUMERAL OSTEOTOMY



6 Years old after 6 surgical procedures at outside hospital


Surgical Procedures by Dr. Nath

1.MODIFIED QUAD2.TRIANGLE TILT



6 Year old child following surgery at outside hospital:

1. Nerve grafting2. Muscle transfer3. Shoulder joint surgery4. Biceps to triceps transfer (cadaver tissue)5. Biceps tendon cadaver graft6. Humeral osteotomy After Modified quad and Triangle tilt surgeries


ConclusionsConclusions• Nerve repair in children may not be

required as frequently• Muscle and bony surgeries simpler,

effective• Prognosis excellent with appropriate

surgical management


Disclaimer

This presentation is intended as an informational resource only for therapists working with peripheral nerve injuries. This is a general outline of Dr. Nath’s management protocols; other specialists may have different protocols. Many other surgeries or therapy management may be indicated in more complex or less complex cases. No attempt to provide specific medical advice is intended. It is not intended to infer that surgery is always the best choice for a particular nerve injury. You should always contact a specialist directly for diagnosis and treatment of your specific problem, and a second opinion is always a good idea.

ALL INFORMATION IS PROVIDED AS A PUBLIC SERVICE AND NEITHER GUARANTEE NOR WARRANTY IS EXPRESSED OR IMPLIED.


Questions / Suggestions

Dr. Rahul K. Nath.Texas Nerve and Paralysis Institute

6400 Fannin St, Ste # 2420Houston Texas - 77030

[email protected]: 713-592-9900Fax: 713-592-9921

Websiteswww.texasnerveinstitute.com

www.drnathbrachialplexus.comwww.drnathwingingscapula.com

www.drnathfootdrop.comwww.drnathnervetumor.com

mailto:[email protected]

http://www.texasnerveinstitute.com/

http://www.drnathbrachialplexus.com/

http://www.drnathwingingscapula.com/

http://www.drnathfootdrop.com/

http://www.drnathnervetumor.com/

Surgical Concepts and Techniques in Pediatric Brachial Plexus … · 2012-05-25 · deformities in...

Documents

Transcript of Surgical Concepts and Techniques in Pediatric Brachial Plexus … · 2012-05-25 · deformities in...